Provider Demographics
NPI:1265505226
Name:SHANAHAN, BRYAN J (DDS)
Entity Type:Individual
Prefix:
First Name:BRYAN
Middle Name:J
Last Name:SHANAHAN
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:BRYAN
Other - Middle Name:J
Other - Last Name:SHANAHAN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:DDS
Mailing Address - Street 1:750 N KENDRICK ST STE 100
Mailing Address - Street 2:
Mailing Address - City:FLAGSTAFF
Mailing Address - State:AZ
Mailing Address - Zip Code:86001-3067
Mailing Address - Country:US
Mailing Address - Phone:928-774-2500
Mailing Address - Fax:
Practice Address - Street 1:750 N KENDRICK ST STE 100
Practice Address - Street 2:
Practice Address - City:FLAGSTAFF
Practice Address - State:AZ
Practice Address - Zip Code:86001-3067
Practice Address - Country:US
Practice Address - Phone:928-774-2500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-16
Last Update Date:2019-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ42411223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ860783790OtherTAX ID